BACKGROUND:Impaired perineal wound healing has become a significant clinical problem after abdominoperineal resection for rectal cancer. The increased use of neoadjuvant radiotherapy and wider ...excisions might have contributed to this problem.
OBJECTIVE:The primary aim of this systematic review with meta-analysis was to determine the impact of radiotherapy and an extralevator approach on perineal wound healing after abdominoperineal resection for rectal cancer.
DATA SOURCES:In March 2014, electronic databases were searched.
STUDY SELECTION AND INTERVENTIONS:Studies describing any outcome measure on perineal wound healing after abdominoperineal resection for rectal cancer were included.
MAIN OUTCOME MEASURES:The primary end point was overall perineal wound problems within 30 days after conventional or extralevator abdominoperineal resection with or without neoadjuvant radiotherapy. Secondary end points were primary wound healing, perineal hernia rate, and the effect of biological mesh closure on perineal wound problems.
RESULTS:A total of 32 studies were included. The pooled percentage of perineal wound problems after primary perineal wound closure in patients who did not undergo neoadjuvant radiotherapy was 15.3% (95% CI, 12.1–19.2) after conventional abdominoperineal resection and 14.8% (95% CI, 9.5–22.4) after extralevator abdominoperineal resection. After neoadjuvant radiotherapy, perineal wound problems occurred in 30.2% (95% CI, 19.2–44.0) after conventional abdominoperineal resection and in 37.6% (95% CI, 18.6–61.4) after extralevator abdominoperineal resection. Radiotherapy significantly increased perineal wound problems after abdominoperineal resection (OR, 2.22; 95% CI, 1.45–3.40; p < 0.001). After biological mesh closure of the pelvic floor following extralevator abdominoperineal resection with neoadjuvant radiotherapy, the percentage of perineal wound problems was 7.3% (95% CI, 1.5–29.3).
LIMITATIONS:Heterogeneity was high for some analyses.
CONCLUSION:Neoadjuvant radiotherapy significantly increases perineal wound problems after abdominoperineal resection for rectal cancer, whereas the extralevator approach seems not to be of significant importance.
Aim
The aim of this systematic review was to analyse recurrence rates after different surgical techniques for perineal hernia repair.
Method
All original studies (n ≥ 2 patients) reporting recurrence ...rates after perineal hernia repair after abdominoperineal resection (APR) were included. The electronic database PubMed was last searched in December 2021. The primary outcome was recurrent perineal hernia. A weighted average of the logit proportions was determined by the use of the generic inverse variance method and random effects model.
Results
A total of 19 studies involving 172 patients were included. The mean age of patients was 64 ± 5.6 years and the indication for APR was predominantly cancer (99%, 170/172). The pooled percentage of recurrent perineal hernia was 39% (95% CI: 27%–52%) after biological mesh closure, 29% (95% CI: 21%–39%) after synthetic mesh closure, 37% (95% CI: 14%–67%) after tissue flap reconstruction only and 9% (95% CI: 1%–45%) after tissue flap reconstruction combined with mesh.
Conclusion
Recurrence rates after mesh repair of perineal hernia are high, without a clear difference between biological and synthetic meshes. The addition of a tissue flap to mesh repair seemed to have a favourable outcome, which warrants further investigation.
Quality of life in patients with a perineal hernia Kreisel, Saskia I.; Sharabiany, Sarah; Rothbarth, Joost ...
European journal of surgical oncology,
December 2023, 2023-12-00, 20231201, Letnik:
49, Številka:
12
Journal Article
Recenzirano
Odprti dostop
Patients who develop a perineal hernia after abdominoperineal resection may experience discomfort during daily activities and urogenital dysfunction, but the impact on quality of life has never been ...formally assessed.
Patients who underwent abdominoperineal resection for rectal cancer between 2014 and 2022 in two prospective multicenter trials were included. Primary outcome was defined as median overall scores or scores on functional and symptom scales of the following quality of life questionnaires: 5-level version of the 5-dimensional EuroQol, Short Form-36, and European Organization for Research and Treatment of Cancer QoL Questionnaire Colorectal cancer 29 and 30, Urogenital Distress Inventory-6, Incontinence Impact Questionnaire-7.
Questionnaires were available in 27 patients with a perineal hernia and 62 patients without a perineal hernia. The 5-dimensional EuroQol score was significantly lower in patients with a perineal hernia (83 vs 87, p = 0.048), which implies a reduced level of functioning. The median scores of pain-specific domains were significantly worse in patients with a perineal hernia as measured by the SF-36 (78 vs. 90, p = 0.006), the EORTC-CR29 (17 vs. 11, p=<0.001) and EORTC-C30 (17 vs. 0, p = 0.019). Also, significantly worse physical (73 vs. 100, p = 0.049) and emotional (83 vs. 100, p = 0.048) functioning based on EORTC-C30 was observed among those patients. Minimally important differences were found for role, physical and social functioning of the SF-36 and EORTC-C30. The urological function did not differ between the groups.
A symptomatic perineal hernia can significantly worsen quality of life on several domains, indicating the severity of this complication.
Reply to the Letter by Bethell and Hallows Eeftinck Schattenkerk, Laurens D.; Eeftinck Schattenkerk, Robert M.; Musters, Gijsbert D. ...
Journal of pediatric surgery,
February 2023, 2023-02-00, 20230201, Letnik:
58, Številka:
2
Journal Article
To determine the effect of biological mesh closure on perineal wound healing after extralevator abdominoperineal resection (eAPR).
Perineal wound complications frequently occur after eAPR with ...preoperative radiotherapy for rectal cancer. Cohort studies have suggested that biological mesh closure of the pelvic floor improves perineal wound healing.
Patients were randomly assigned to primary closure (standard arm) or biological mesh closure (intervention arm). A non-cross-linked porcine acellular dermal mesh was sutured to the pelvic floor remnants in the intervention arm, followed by a layered closure of the ischioanal and subcutaneous fat and skin similar to the control intervention. The outcome of the randomization was concealed from the patient and perineal wound assessor. The primary endpoint was the rate of uncomplicated perineal wound healing defined as a Southampton wound score of less than 2 at 30 days postoperatively. Patients were followed for 1 year.
In total, 104 patients were randomly assigned to primary closure (n = 54; 1 dropouts) and biological mesh closure (n = 50; 2 dropouts). Uncomplicated perineal wound healing rate at 30 days was 66% (33/50; 3 not evaluable) after primary closure, which did not significantly differ from 63% (30/48) after biological mesh closure relative risk 1.056; 95% confidence interval (CI) 0.7854-1.4197; P = 0.7177). Freedom from perineal hernia at 1 year was 73% (95% CI 60.93-85.07) versus 87% (95% CI 77.49-96.51), respectively (P = 0.0316).
Perineal wound healing after eAPR with preoperative radiotherapy for rectal cancer was not improved when using a biological mesh. A significantly lower 1-year perineal hernia rate after biological mesh closure is a promising secondary finding that needs longer follow-up to determine its clinical relevance.
•What is currently known about this topic?.•Altough sometimes necessary, stomas can lead to increased morbidity.•What new information is contained in this article?.•Major stoma related morbidity ...(Clavien-Dindo ≥III) occurs in approximately 25% following stoma formation and closure each. Taking into account both operations, 39% experiences a major stoma related complication. Patients with an ileostomy are significantly most at risk.
Little is known about stoma related morbidity in young children. Therefore, the aim of this study is to assess major morbidity after stoma formation and stoma closure and its associated risk factors.
All consecutive young children (age ≤ three years) who received a stoma between 1998 and 2018 at our tertiary referral center were retrospectively included. The incidence of major stoma related morbidity (Clavien-Dindo grade ≥III) was the primary outcome. This was separately analysed for stoma formation alone, stoma closure alone and all stoma interventions combined. Non-stoma related morbidity was excluded. Risk factors for major morbidity were identified using multivariable logistic regression analysis.
In total 336 young children were included with a median follow-up of 6 (IQR:2–11) years. Of these young children, 5% (n = 17/336) received a jejunostomy, 57% (n = 192/336) an ileostomy, and 38% (n = 127/336) a colostomy. Following stoma formation, 27% (n = 92/336) of the young children experienced major stoma related morbidity, mainly consisting of high output stoma, prolapse and stoma stenosis. The major morbidity rate was 23% (n = 66/292) following stoma closure, most commonly comprising anastomotic leakage/stenosis, incisional hernia and adhesive obstructions. For combined stoma interventions, major stoma related morbidity was 39% (n = 130/336). Ileostomy was independently associated with a higher risk of developing major morbidity following stoma formation (OR:2.5; 95%-CI:1.3–4.7) as well as following closure (OR:2.7; 95%-CI:1.3–5.8).
Major stoma related morbidity is a frequent and severe clinical problem in young children, both after stoma formation and closure. The risk of morbidity should be considered when deliberating a stoma.
Aim
Uncontrolled pelvic sepsis following rectal cancer surgery may lead to dramatic consequences with significant impact on patients' quality of life. The aim of this retrospective observational ...study is to evaluate management of pelvic sepsis after total mesorectal excision for rectal cancer at a national referral centre.
Method
Referred patients with acute or chronic pelvic sepsis after sphincter preserving rectal cancer resection, with the year of referral between 2010 and 2014 (A) or between 2015 and 2020 (B), were included. The main outcome was control of pelvic sepsis at the end of follow‐up, with healed anastomosis with restored faecal stream (RFS) as co‐primary outcome.
Results
In total 136 patients were included: 49 in group A and 87 in group B. After a median follow‐up of 82 months (interquartile range 35–100) in group A and 42 months (interquartile range 22–60) in group B, control of pelvic sepsis was achieved in all patients who received endoscopic vacuum assisted surgical closure (7/7 and 2/2), in 91% (19/21) and 89% (31/35) of patients who received redo anastomosis (P = 1.000) and in 100% (18/18) and 95% (41/43) of patients who received intersphincteric resection (P = 1.000), respectively. Restorative procedures resulted in a healed anastomosis with RFS in 61% (17/28) of patients in group A and 68% (25/37) of patients in group B (P = 0.567).
Conclusion
High rates of success can be achieved with surgical salvage of pelvic sepsis in a dedicated tertiary referral centre, without significant differences over time. In well selected and motivated patients a healed anastomosis with RFS can be achieved in the majority.
Chronic pelvic sepsis mostly originates from complicated pelvic surgery and failed interventions. This is a challenging condition that often requires extensive salvage surgery consisting of complete ...debridement with source control and filling of the dead space with well-vascularized tissue such as an autologous tissue flap. The abdominal wall (rectus abdominis flap), or leg (gracilis flap) are mostly used as donor sites for this indication, while gluteal flaps might be attractive alternatives.
To describe the outcomes of gluteal fasciocutaneous flaps for the treatment of secondary pelvic sepsis.
Retrospective single center cohort study.
Tertiary referral center.
Patients who underwent salvage surgery for secondary pelvic sepsis between 2012 and 2020 using a gluteal flap.
Percentage of complete wound healing.
In total, 27 patients were included, of whom 22 underwent index rectal resection for cancer and 21 patients had undergone (chemo)radiotherapy. A median of three (IQR 1-5) surgical and one (IQR 1-4) radiological intervention preceded salvage surgery during a median period of 62 (IQR 20-124) months. Salvage surgery included partial sacrectomy in 20 patients. The gluteal flap consisted of a V-Y flap in 16 patients, superior gluteal artery perforator flap in eight, and a gluteal turnover flap in three patients. Median hospital stay was nine (IQR 6-18) days. During a median follow up of 18 (IQR 6-34) months, wound complications occurred in 41%, with a re-intervention rate of 30%. The median time to wound healing was 69 (IQR 33-154) days with a complete healing rate of 89% at the end of follow-up.
Retrospective design and heterogeneous patient population.
In patients undergoing major salvage surgery for chronic pelvic sepsis, the use of gluteal fasciocutaneous flaps is a promising solution due to the high success rate, limited risks, and relatively simple technique. See Video Abstract at http://links.lww.com/DCR/C160.
•What is currently known about this topic?.•Adhesions following abdominal surgery can cause small bowel obstruction (SBO).•What new information is contained in this article?.•SBO occurs in 5% of ...young children, which is higher than in older children. Following laparoscopy, 1% develop SBO. Gastroschisis, necrotizing enterocolitis and intestinal atresia are most at risk. History of stoma, emergency surgery and postoperative infections are independent risk factors.
Adhesions following abdominal surgery can cause small bowel obstruction (SBO) necessitating surgery. Whilst some studies have addressed SBO in children, the incidence of SBO, the diseases that are of increased risk as well as risk factors in young children remain unclear. Therefore, this study aims to determine; (1) the general incidence of SBO in young children, (2) which diseases entail highest incidence of SBO and (3) risk factors for SBO in young children.
Young children (≤ 3 years of age) who underwent abdominal surgery in our tertiary referral centre between 1998–2018 were retrospectively included. Both general incidence and incidence per disease of SBO were determined. Independent risk factors for SBO were identified using cox-regression.
The incidence of SBO was 5% (N = 88/1931) in our cohort. Five of the SBOs developed following laparoscopic treatment. Patients treated for gastroschisis (17%,N = 9/53), necrotizing enterocolitis (8%,N = 15/188) and intestinal atresia (7%,N = 13/177) were at high risk of experiencing SBO. Diaphragmatic hernia (28%,N = 7/25) and meconium ileus (28%,N = 7/25) also showed high SBO proportions. Having a history of stoma (HR:3.2, 95%-CI:2.0–5.2), undergoing emergency surgery (HR:2.2, 95%-CI:1.3–3.7) and postoperative infections (HR:1.9, 95%-CI:1.2–3.1) were general risk factors for the development of SBO.
The incidence of SBO in young children seems higher than what has previously been reported in older children, which is why they should be studied separately. The incidence of SBO differs between diseases. Having a history of a stoma, emergency surgery and postoperative infections were independent risk factors for SBO development. Although less at risk, SBOs do develop after laparoscopies, which is why they should be included in more long-term follow-up studies.
II
: Surgical site infections (SSI) are a frequent and significant problem understudied in infants operated for abdominal birth defects. Different forms of SSIs exist, namely wound infection, wound ...dehiscence, anastomotic leakage, post-operative peritonitis and fistula development. These complications can extend hospital stay, surge medical costs and increase mortality. If the incidence was known, it would provide context for clinical decision making and aid future research. Therefore, this review aims to aggregate the available literature on the incidence of different SSIs forms in infants who needed surgery for abdominal birth defects.
: The electronic databases Pubmed, EMBASE, and Cochrane library were searched in February 2020. Studies describing infectious complications in infants (under three years of age) were considered eligible. Primary outcome was the incidence of SSIs in infants. SSIs were categorized in wound infection, wound dehiscence, anastomotic leakage, postoperative peritonitis, and fistula development. Secondary outcome was the incidence of different forms of SSIs depending on the type of birth defect. Meta-analysis was performed pooling reported incidences in total and per birth defect separately.
: 154 studies, representing 11,786 patients were included. The overall pooled percentage of wound infections after abdominal birth defect surgery was 6% (95%-CI:0.05–0.07) ranging from 1% (95% CI:0.00–0.05) for choledochal cyst surgery to 10% (95%-CI:0.06–0.15) after gastroschisis surgery. Wound dehiscence occurred in 4% (95%-CI:0.03–0.07) of the infants, ranging from 1% (95%-CI:0.00–0.03) after surgery for duodenal obstruction to 6% (95%-CI:0.04–0.08) after surgery for gastroschisis. Anastomotic leakage had an overall pooled percentage of 3% (95%-CI:0.02–0.05), ranging from 1% (95%-CI:0.00–0.04) after surgery for duodenal obstruction to 14% (95% CI:0.06–0.27) after colon atresia surgery. Postoperative peritonitis and fistula development could not be specified per birth defect and had an overall pooled percentage of 3% (95%-CI:0.01–0.09) and 2% (95%-CI:0.01–0.04).
: This review has systematically shown that SSIs are common after correction for abdominal birth defects and that the distribution of SSI differs between birth defects.
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